General Anesthesia and Scalp Block for Craniotomy Due to Cerebral Abscess in Uncorrected Tetralogy of Fallot Patient: A Case Report and Literature Review

Abstract

Introduction: Neurosurgery in Tetralogy of Fallot (ToF) poses complex anesthetic challenges due to risks of hypoxemia and hemodynamic instability. The aim of this case report was to describe the general anesthesia and scalp block management of a boy with uncorrected ToF who developed a cerebral abscess requiring craniotomy for abscess drainage.
Case: An 8-year-old boy with uncorrected ToF presented with headache, fever, and neurological deficits. Neuroimaging revealed a large frontal abscess necessitating urgent surgical intervention. Preoperative evaluation showed central cyanosis, digital clubbing, and oxygen saturation of 70% on room air, with echocardiography demonstrating a significant right-to-left shunt. The primary anesthetic objectives were to maintain systemic vascular resistance (SVR) and prevent increases in pulmonary vascular resistance (PVR). Anesthesia induction was achieved with ketamine 1 mg/kg and fentanyl 4 µg/kg to preserve SVR, followed by rocuronium 0.5 mg/kg for neuromuscular relaxation. A bilateral scalp block was administered with ropivacaine 0.25% (0.4 mL/kg per site) for regional analgesia. The surgery was completed without complications, and the patient was extubated safely after 24 hours in the pediatric intensive care unit.
Discussion: Anesthetic management of uncorrected ToF during neurosurgery focuses on maintaining SVR and avoiding increases in PVR to prevent worsening right-to-left shunting and hypoxemia. Ketamine-based induction and bilateral scalp block provided hemodynamic stability and effective analgesia, facilitating successful surgical and postoperative outcomes without major complications
Conclusion: Individualized anesthetic management that prioritizes SVR preservation, PVR control, and meticulous hemodynamic monitoring is essential for safe neurosurgical procedures in uncorrected ToF.